The Medical Community’s Efforts to Promote
Advance Care Planning

To encourage advance care planning, Medicare recently announced it will reimburse physicians and medical professionals for conducting end-of-life conversations.⁷ The problem is, most medical professionals have had little or no training in advance care planning or how to converse with patients.⁸

However, medical schools such as U.C. San Francisco and Stanford University are now offering courses on advance care planning and communication skills. Both Stanford and UCSF use immersion learning techniques that involve medical students participating in class exercises with their fellow students and role-playing with actors, sometimes in front of video cameras.

In Dr. Brook Calton’s UCSF course on advance care planning and improving communication skills, medical students are learning how to carry on conversations by taking turns playing the roles of patients and doctors. Empathy and sensitive

language are important when talking to dying patients and their families. Calton told her students that in the past, most physicians had paternalistic attitudes and “I know what’s best” and “This is what you have to do.” Those attitudes are starting to change, but Calton says even today, many doctors tend to interrupt their patients and not listen. Her students are learning to listen closely to patients and converse with them, using simple language without the medical jargon. Open-ended questions such as “What brings you joy?” or “If time were short, what is most important to you?” are good ways to start a conversation. That can lead the way to more difficult follow-up questions such as “We’re worried you’re not getting better. What do you know?” and “How much do you want to know?”

Carrying on an end-of-life conversation can be difficult and awkward at first. It takes skill and patience to find the right language. “You feel tongue-tied, telling a patient, because you don’t know whether they will start crying,” said Stanford’s palliative care director Periyakoil, “You don’t know whether you can control your emotions, so it’s incredibly important to role-play this.”

She added, “The key is, you need to be able to voice these words out loud, in a safe environment where you’re not talking to a real patient. Because you don’t want to be with a real patient who’s in distress, try your skills, and get it wrong.”

It’s Never Too Soon to Start the Conversation

Advance care planning is not just for the elderly or the terminally ill. Death can occur at any age, and it’s good to be prepared, in case the unexpected happens. In her role as a palliative care specialist at U.C. San Francisco, Dr. Dawn Gross has led many end-of-life conversations with patients of all ages. On her KALW call-in show Dying to Talk,⁹ Gross recently led an on-air advance care planning discussion with her two teenage children Josh and Isabell. Gross wanted to make sure they know and understand their parents’ final wishes, without all the guessing and uncertainty. “The best way to free us is to have these conversations, so that we can find ways to honor peoples’ lives,” said Gross, “This is so not about ‘how do you want to die’ because we have no control over that. It’s how do you want to live until you die and the only way to know is to talk about it.”

My father and I never had that discussion. After spending nearly a month in a skilled nursing facility following his collapse, he was more than ready to go home. We dodged the bullet this time. But my father is nearing the end of his life. Issues around CPR, shock treatment, and ventilators will come up again and I still have no clear answers. My father is now very frail and has dementia. It’s too late to have that end-of-life conversation. Complex questions are now beyond his comprehension. Like many family members who waited too late, I’ll have to make my best guess at what his wishes would be when we cross that bridge.

JoAnn Mar’s report is part of The End of Life Radio Project, made possible by a grant from the Association of Health Care Journalists and The Commonwealth Fund.

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